UC Berkeley Web Feature
Amani Nuru-Jeter hopes to unravel race vs. racism's role in health
BERKELEY – In the United States, being black is dangerous to your health. Adjusted for age, the African-American death rate from strokes was 43 percent higher than for Caucasians, 31 percent higher for heart disease, and 23 percent higher for cancer, according to the National Center for Health Statistics. Yet for a long time, public-health research has treated race as a "nuisance" variable, one much less important than factors like income and education level.
A new generation of researchers, like Amani Nuru-Jeter, assistant professor at UC Berkeley's School of Public Health, is starting to look at the data from a very different angle. Maybe the important part is not that rich black corporate lawyers tend to be as healthy as rich white corporate lawyers, but that there are so few of the former compared to the latter. Maybe the variable to look at is not race, but racism.
"It's not a coincidence that blacks are overrepresented in low-income groups, and whites are overrepresented in high-income groups," said Nuru-Jeter over a recent salad at Jupiter. "Rather, the history of racial discrimination in this country has systematically placed different racial groups into different levels of socioeconomic status, or SES, which has persisted over time. So then, how important is it for us to ask whether [the culprit is] race or SES? I would suggest that instead of trying to figure out which is more important, that we should try to better understand how the two interact."
In essence, Nuru-Jeter and other public health researchers like her are at the beginning of trying to answer a rather controversial question: What if a person's constant, stress-inducing experiences with discrimination are more likely to cause poor health than are the tiny biological differences associated with skin color?
Nuru-Jeter has often found herself in situations "where I am the only one of me, what we call 'solo status,' whether it’s because of my color, gender, both, or the kind of research that I do," she shrugs. She first stood out in the elementary-school cafeteria. For health reasons, her mother was raising Amani and her younger sister as vegetarians, which was not so common in Washington, D.C., at the time.
"Oh, how we hated it," she recalls. "I remember I once traded my lunch for a ham sandwich, and when the other girl found out she'd ended up with an olive and cream-cheese sandwich, she was so mad."
The vegetarianism didn't stick, but her religious upbringing did. Nuru-Jeter's Christianity "is a big part of who I am as a person," she says. "I don't think of it as a religion; I just think of it as how I live my life." The reason why she's picking at a bare-bones spinach salad while I chomp down on a big, greasy veggie burger is that she's gearing up for a 40-day juice fast. "Every year I like to take time to sacrifice something that will remind me to go into deeper devotion to God," she explains. Her hunger pains remind her to pray. "But don't worry, as a public-health person I know I have to supplement my diet, to make sure I'm getting all the protein and other nutrients that I need."
Nuru-Jeter's path to public health started out as a tangent. She grew up wanting to be a doctor and was pre-med at the University of Maryland, majoring in biology and neurophysiology. "I didn't know what kind of doctor I wanted to be, but I always wanted to be one," she recalls. "I had a lot of illness in my family, and I was just fascinated by the idea of being able to help people become healthier, stronger, and more vibrant."
'I would suggest that it didn't just happen that blacks are overrepresented in low-income groups and whites are overrepresented in high-income groups. Perhaps a history of racial discrimination in this country has really systematically placed group in different levels of socioeconomic status.'
Knowing how competitive it was to get into medical school, she worried that her grades were not good enough and asked herself, "what about Amani is going to stand out?" She had attended a lot of medicine-related conferences as an undergraduate and noticed that many of the speakers had MD/MPH next to their names, indicating a joint master's degree in medicine and public health.
"I was like, what's 'public health'?" she laughs. "Then I figured that if most MDs have MPHs — you know, based on my small sample size — I might as well get mine now and apply to medical school afterward, thinking that will make me a more competitive applicant."
Not wanting to leave the Washington area, she applied to the only MPH program in D.C., George Washington University's. In order to pay for the program, which was geared to working people, she took a paid internship at D.C.'s Department of Health, working full time in the primary care office. It turned out to be the perfect match: Nuru-Jeter found herself on the front lines of public health policy as she studied its history by day and its underpinnings at night.
Black and white terms
Working with both the city's public and nonprofit health clinics, she was called on to help investigate, for example, why people who were eligible for Medicaid were not enrolled or falling through the cracks of the health-care net in other ways. After helping with a full-scale needs assessment of the primary-care system in D.C., Nuru-Jeter began working on J-1 visa waiver applications that would bring qualified doctors from outside the United States to work in underserved urban areas for a two-year term.
This potent combination of classroom and fieldwork "totally transformed my focus from wanting to deliver one-on-one patient care, to wanting to be in a position to inform policy that would affect populations of people at a time," Nuru-Jeter says. Choosing her words carefully, she explains that she was partly motivated by the fact that when she sat at the table with the Washington, D.C. city council and the heads of agencies to discuss, for example, how best to create and fund a children's health insurance program, she was dismayed to realize that the people forming these policies and determining where the money would go were not only untrained in public health, but "were making a lot of unfounded assumptions about what these communities look like, and forming policies based on not a whole lot of information."
Nuru-Jeter was, as she and others in her work life saw it, "just a student, and more often than not — if not always — the only person of color, or the only woman of color, at these tables where local public health policy was literally being formed." She was not confident enough to point out to the bigwigs that sometimes they were "grossly misrepresenting" the population that they were trying to serve. She decided that the only way she would have a real voice in such discussions was to go get another credential. After finishing her M.P.H. in maternal and child health at George Washington — the children's health insurance program she had worked on became the subject of her master's thesis — she went for a Ph.D. in health policy and management at Johns Hopkins Bloomberg School of Public Health, finishing in May 2003.
Her dissertation looked at the roles of racial residential segregation and concentrated poverty by race in the relationship between income inequality and mortality. She found that for an African-American person, living in a primarily all-black community as opposed to a more diverse one tended to have a negative effect on their health. The opposite was true for whites.
But, I ask, referring back to income as a predictor of health, "Isn't an all-white community more likely to be a gated suburb for rich people, versus an all-black area, which has a greater chance of being urban and low income?"
Nuru-Jeter gently reminds me that such an assumption is an example of unconscious bias, where "all white" assumes "positive socioeconomic status" and "all black," the opposite. Such assumptions aside, "all-black middle-class and upper-middle-class metropolitan areas do exist, and I studied those as well," she answers. And the African-Americans living in those communities still had poorer health than their middle-class white counterparts. "There was enough to suggest that there was an independent relationship, that race and socioeconomic status interact with one another in ways we don't yet understand."
Quantifying the experience of racism
After finishing her dissertation, Nuru-Jeter came to Berkeley as a Robert Wood Johnson Health & Society Scholar, in a two-year position similar to a postdoctoral fellowship. The Robert Wood Johnson Foundation sponsors a national program intended to build up the field of population health, which looks at why some groups of people are healthy and others are not. When the fellowship ended, she decided to stay at UC Berkeley, joining the faculty in 2005.
This semester, she's teaching social epidemiology, which looks at how social and psychological factors affect the distribution of disease in populations, to graduate students. She loves teaching the class. "I encourage my students to be scholars, not researchers. Not to be data driven, but theory driven — to ask the tough questions and then go find the data that can test your idea," she says.
That's the only way to change how public health research and practice happens, she contends. Ten years ago, few schools of public health even offered classes on racism. There is still some resistance to studying the social determinants of health. Nuru-Jeter says she often makes the mistake of thinking that everyone thinks like her, that social risk factors matter in and of themselves, rather than because they muddle the other relationships being looked at. "If people like me continue to remove ourselves and stay out of these circles, we're not going to be able to change policy, school curricula, or anything else," she says. "My hope, and I think that of the Robert Wood Johnson Scholars Program, is to gain access to these different environments where we can influence the research questions that get asked, and where we can be part of fostering a new generation of scholars who will also challenge our thinking about population health and health inequalities."
Nuru-Jeter is working on developing a tool with which she hopes to answer that question of whether racism, as part of the lived and social experience of race, is at least partly to blame for African-Americans' comparatively poorer health. Through an interdisciplinary project based out of the Center on Social Disparities and Health at UC San Francisco, she has helped conduct multiple focus groups of black women all across the Bay Area in which the women were asked about their experiences of racism at different life stages. She hopes to correlate these experiences to actual birth outcomes. Relying on the resulting 50-page transcripts of these free-ranging conversations, she and the other researchers will also attempt to identify recurring words and phrases that can be used to build a survey of racism, with funding from the Centers for Disease Control and the Robert Wood Johnson Foundation.
The problem with current surveys, she says, is that their questions ask, for example, whether the respondent has experienced unfair treatment because of their race in any one of these settings: work, housing, etc. "What we've found in our work is that yes, it's getting housing, it's interfacing with the police system, it's applying for jobs, and on and on and on — these women talked about having discriminatory experiences in every single area you can imagine," Nuru-Jeter says. "So perhaps instead of having a list with five domains, we need to figure out how to capture the chronic and pervasive nature of racism that affects women across every area of their life, not just the few that seem to be most obvious. What we need to know is how to quantify experiences they may have had during pregnancy and during other life stages."
Nuru-Jeter is also working on a study to examine the role of racial discrimination plays in racial differences in other measures of biological stress like "allostatic load," a composite of blood pressure, waist-hip ratio, and other critical biomarkers. Although allostatic load does have its detractors, she says, it is gaining traction as a measure of the wear and tear that chronic stress exacts on the body.
"The hypothesis is that there is some type of mind-body process, a psychophysiology associated with one's social experience in the world, that is translated and gets into the body to affect health outcomes. When a person experiences an environmental assault, or any kind of assault, there is a stress response: your insulin, adrenaline, and epinephrine levels go up," she explains, adding that the human body has an internal mechanism that returns these levels to stable after a period of time … usually. "The idea behind allostatic load, however, is that perhaps repeated assaults don’t allow the body to regain its balance properly."
As a former English major struggling with the science that Nuru-Jeter is cheerfully zooming through, I present a hypothetical example. Say an African-American woman has experienced discriminatory treatment a few times at the hands of police officers, and each instance has exacted a physiological toll. Will her pulse race and her breathing quicken every future time she sees a cop? Seems reasonable to me. But is it this kind of constant exposure to a heightened level of stress that might account for higher rates of poor health?
Ever the careful researcher, Nuru-Jeter will not bite. "Right now, we're just taking the first step toward understanding the process," she says. "But what we do know is that it is more than just saying that 'race matters' or 'socioeconomic status matters.' The questions for me are, How does race matter, how does socioeconomic status matter, and how do the two matter together?"